Provider Demographics
NPI:1508047846
Name:NORTHSIDE DERMATOLOGY ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:NORTHSIDE DERMATOLOGY ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEWART
Authorized Official - Middle Name:E
Authorized Official - Last Name:WIEGAND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-256-5611
Mailing Address - Street 1:755 MOUNT VERNON HWY
Mailing Address - Street 2:SUITE 110
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-4274
Mailing Address - Country:US
Mailing Address - Phone:404-256-9692
Mailing Address - Fax:404-256-9404
Practice Address - Street 1:755 MOUNT VERNON HWY
Practice Address - Street 2:SUITE 110
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-4274
Practice Address - Country:US
Practice Address - Phone:404-256-9692
Practice Address - Fax:404-256-9404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-15
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA012988174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00176481CMedicaid
GACM5399OtherRAILROAD MEDICARE
GACM5399OtherRAILROAD MEDICARE